The featured document is ‘Transforming the Quality of Dementia Care: Consultation on a National Dementia Strategy’ and freely available here.
There is an introduction by Alan Milburn MP, Secretary of State for Health in which he states that the government has identified dementia as a national priority. In the development of a national strategy, he states that the 3 main areas that have been focused on are improving awareness of dementia, ensuring early diagnosis and delivering high quality care and support to those with dementia. He also gives acknowledgments to the members of the project working group.
There then follows an introduction by Ivan Lewis MP, Parliamentary Under-Secretary of State for Care Services who identifes this consultation as ‘one of the most important stages in the development of that strategy’. He emphasises the important values of maintaining dignity and respect for people with dementia.
There is then an introduction by two of the joint leads on the project Professor Sube Banerjee and Jenny Owen. In this introduction the authors emphasise that a change in culture is required, where stigma and ‘false beliefs’ are abolished and corrected respectively. They describe how the experiences for people with dementia should change from the initial stage of diagnosis onwards.
In the Executive Summary, there is a discussion of the need to take a strategic approach and the ability to do so given recent advances in understanding of dementia. They reference the Dementia UK report from the Alzheimer’s Society in particular as giving an indication of ‘projections of future growth’, the NICE and SCIE documents and the analyses conducted by the National Audit Office. The figures given for dementia are disturbing – 24.3 million people worldwide, an estimate of 700,000 in the UK, a doubling in the next 30 years and current costs of 17 billion a year. Comorbidity and the demands on caregivers, often elderly are further complications. Dementia policies are described in terms of other relevant policies including ‘Our NHS, Our Future’, the Carers’ Strategy and the National End of Life Care Strategy. Within the Executive Summary there is a more detailed discussion of the three main areas of the strategy. Thus in improving awareness there is a reference to increasing public and professional awareness and also creating an informed and effective workforce. In terms of early diagnosis and intervention there is a focus on ‘good-quality early diagnosis’, ‘good-quality information’ and ‘continuity of support and advice’. With regards to high-quality care and support there are a number of recommendations: Improved quality of care in general hospitals, improved home care and short breaks, a joint commissioning strategy for dementia, improved dementia care in care homes, improved registration and inspection of care homes and ‘intermediate care for people with dementia’. In delivering the National Dementia Strategy there is a focus on provision of information on the strategy, identifying ‘research evidence and needs’ and ‘effective support for implementation’.
There is also a partial impact assessment which examines possible implications of implementing the strategy in economic and social terms. The strategy is then described in terms of how it relates to the Strategic Health Authorities, health and social care commissioners and to different communities. The general principles are quite interesting in that they suggest a need for clarity in relating the strategy to a number of other policies, a seemingly complex task. So the strategy will be ‘consistent with the relevant National Service Frameworks’, ‘address the recommendations of the …… report Improving services and support for people with dementia’. The process of developing the strategy is then described which involved a working group and an external group chaired by Neil Hunt, the Chief Executive of the Alzheimer’s Society.
In ‘Setting the Scene’, there is a description of a person with dementia and their experience of different parts of the health service. The case highlights some of the difficulties that are addressed by the National Strategy for Dementia. In the section ‘What is the impact of dementia?’ there is a discussion of what dementia means and further details of the impact that dementia has on society. There is an outline of some of the broader difficulties in service delivery. In the section on the ‘Policy Framework’, there is a discussion of some of the relevant policies as mentioned above. In the ‘Wider Policy Context’, there is a discussion of some other policies in related areas again some of which are mentioned above. In ‘Issues for commissioners and service providers’, the authors identify the need to place the implications of the strategy in the context of general mental health service provision.
The implementation plan as expected is quite complex and ‘will rely on using existing levers to drive forward the strategy’, these levers including local commissioning policy, the care quality commission, Lord Darzi’s ‘Our NHS, Our Future’ initiative and a number of other projects.
Chapter 1 focuses on improved awareness and begins with quotes from carers or people with dementia. Recommendation 1 – increased public and professional awareness is discussed and objectives for the public described. In so doing, there is perhaps the implication that such objectives will be achieved through education of the population, in effect improving ‘common’ knowledge about dementia. Challenging the false beliefs of ‘nothing can be done’ and dementia as a ‘normal part of ageing’ are important examples of these objectives. These objectives are to be achieved through public education and professional and vocational training. Component points that should be included in such training and education are then listed. The second recommendation about the workforce is then discussed in more detail. The need for all parts of the workforce to have training in dementia is highlighted and the benefits in improving staff morale also emphasised. ‘Kite-marking’ of good practice is suggested as a means for helping commissioners to choose effective training packages. A list of consultation questions are included at the end of this chapter.
In Chapter 2 there is a focus on early diagnosis and intervention again beginning with quotes from carers and people affected by dementia. The recommendation on ‘good quality early diagnosis and intervention for all’ is described in more detail and the objectives here include ‘immediate treatment, care and support following diagnosis’. In the background section, there is a staggering figure from the National Audit Office’s report showing that ‘less than half of people with dementia ever receive a formal diagnosis’. This is another particularly interesting part of the document as it supports the development of early diagnostic and intervention services for dementia, similar to the concept of those developed in general adult services for psychosis. In the fourth recommendation, there is a discussion of good quality information being available and the suggestion that this is developed nationally (the possibility of utilising internet technology here might be interesting). In the fifth recommendation, there is discussion of continuity of support and advice. The idea of a ‘dementia care adviser’ discussed here is quite interesting, a person who signposts to relevant services. As in the previous chapter, there are some consultation questions at the end.
The third chapter focuses on ‘high-quality care and support’ again beginning with quotes from carers and people with dementia. Here the objectives are to improve the quality of care in all relevant environments. The authors identify changes needed to implement these objectives. For instance the Public Accounts Committee’s report identifies the needs of people with dementia in care homes. The potential for abuse is also mentioned. The need for research in effective interventions in this area is highlighted. The sixth recommendation focuses on improving quality of care in general hospitals and stating that 70% of acute hospital beds are currently ‘occupied by older people’ and that <=50% of these people may have cognitive impairment. The difficulties in managing these large numbers in the hospital environment are discussed. Three methods suggested for improving care in the hospital enviroments are identifying a senior lead clinician, developing care pathways and commissioning mental health liaison teams.
Recommendations 7-9 are considered together, joint commissioning, improved short breaks and improved home care. The objectives here include continuity, simplicity and responsiveness. The authors then identify what changes are needed for these objectives to be achieved. A number of the findings in this area are discussed and then recommendations made such as access to expert patient programmes and telecare facilities. In recommendation 10, intermediate care is discussed. Here the authors discuss some prejudices that may prevent people with dementia from accessing rehabilitation including reduced expectations of benefits and an expectation that increased length of time in rehabilitation is needed. Recommendations 11 and 12 (improved care in care homes and registration and inspection of care homes) are discussed together. The findings in the Home from Home report by the Alzheimer’s Society are discussed including the relative lack of activities for the person with dementia as reported by carers. The mental health needs of people with dementia in care homes as well as the use of antipsychotic medication in these environments are discussed. A number of suggestions for improving care are made including regular mental health reviews. The possibility of building upon existing community mental health teams here as well as accessing in-reach services from other professionals such as geriatricians is also mentioned.
The final chapter is on delivering the National Strategy for Dementia. In recomendation 14, the authors discuss how a research strategy can be developed which can better inform funding agencies. In recommendation 15, the authors focus on support for implementation of the dementia strategy. Here there is a reiteration of earlier points such as leveraging existing services and facilitating the commissioning process as well as other points such as encouraging the development of clinical networks. The authors also state that they will publish a schedule for achieving the strategy to be published after the consultation process.
There follows a number of useful appendices covering project group members, responding to the consultation (ended September 2008), the policy context for the National Dementia Strategy and the case for early diagnostic and intervention services.
This is a consultation document and the National Dementia Strategy has important implications for dementia in the UK. Indeed the Strategy has recently been published and has already generated widespread response in the media (e.g here, here and here).
Steps to Treatment 2 (Consultation Document preceding National Dementia Strategy publication).
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